Big Medicare payouts make sense

Recent reports about individual doctors getting over a million dollars a year in Medicare payments raised a lot of eyebrows. But what may not have been noticed is that most of the doctors were ophthalmologists, which made much more sense out of the reports.

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By ColumnCredit

capecodtimes.com

By ColumnCredit

Posted Apr. 17, 2014 at 2:00 AM

By ColumnCredit

Posted Apr. 17, 2014 at 2:00 AM

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Recent reports about individual doctors getting over a million dollars a year in Medicare payments raised a lot of eyebrows. But what may not have been noticed is that most of the doctors were ophthalmologists, which made much more sense out of the reports.

Ophthalmologists are medical doctors specializing in diseases of the eye, like glaucoma and retinopathy. Recent news stories reported that a small percentage of the doctors in Medicare collected more than $3 million in their practices and 151 ophthalmologists accounted for nearly $658 million in Medicare payments, more than any other disciplines, including famously expensive oncology and cancer specialists. But these doctors are dealing with one of the fastest-growing epidemics in the nation — old age.

There are many causes of blindness, and most of these incurable diseases are diseases of age. One of them is AMD, age-related macular degeneration, which is a progressive eye condition affecting as many as 15 million Americans. About 200,000 new cases are diagnosed every year. The vision loss it causes is severe because it attacks a membrane in the eye called a macula, which is essential to central vision. It causes a black "spot" in the field of vision, which gradually gets larger leaving nothing but increasingly diminishing peripheral vision, and eventually only a black, shadowy hole at the center of vision. As the disease progresses, the macula crumbles and eventually the eye goes "wet" as the membrane allows blood to leak into the eyeball, causing blindness. About 1.75 million Americans have wet AMD, and the vast majority of those with this incurable disease are over age 65, and hence on Medicare.

Avastin was one of the earlier breakthrough drugs. It was developed to treat cancer, but patients who were treated also found their eye disease getting better, and in some cases restoring sight. Along with Lucentis, these injections into the eye helped dry the leakage of blood into the eye through the degenerated macula. Eyelea is the newest medication and is injected into the eye every four to six weeks. A single injection costs about $4,000, so a single year's course of treatment costs about $45,000 — for each affected eye. And that is the cost of the medication alone; it does not include the diagnosis, monitoring, retinal scans, analysis and other necessary treatments by the doctor. It becomes easier to see how quickly a practice could get to a million dollars over the course of a year.

It's easy enough to blame evil drug companies and so on. But when you consider how creative doctors and scientists have been to try to manage this disease, the research costs have been money well spent. Right now, the injections are a management tool that fight a steady but losing fight against the progress of the disease. But AMD has been at the front of stem cell trials for many years and there has been success in producing retinal cells. More recently, researchers at the University of Cambridge used a standard ink-jet printer to form layers of two types of cells taken from the retinas of rats, and they survived and grew in culture. One approach is like planting a seed from pine cone and waiting and hoping for it to grow, and the other is like buying a 6-foot spruce at a garden center. While both lines of inquiry are tremendously costly, both hold the promise of a permanent cure instead of the management by injection.

There's no easy answer for this. Now that health care is solved in the mind of progressives, they are eager to move on to health compensation. Doctors are being urged to move from a fee-for-service model to a new model based upon results and patient improvement. Doctors like ophthalmologists who can do little more than assuage incurable disease are leery of how that would affect them. Paying doctors less won't lessen the costs of medications and treatments any more than cutting nursing home reimbursement will lower staffing and other costs. As the enormous baby boomer generation ages, this is a situation that will only grow worse. Government may live to regret taking over health insurance, so let's find a way that we all won't regret to live.

Cynthia E. Stead is executive director of Sight Loss Services in Dennis. Email her at cestead@gmail.com.